Certified Provider Credentialing Specialist (CPCS) study guide

Certified Provider Credentialing Specialist
The Certified Provider Credentialing Specialist (CPCS) is typically employed or contracted by a healthcare organization including, but not limited to, hospitals (health systems), health plans, ambulatory care settings, group practices, and credentialing verification organizations.

Initial Appointment / Clinical privileges/ practioners covered according to the TJC
All licensed Independent practitioners must be credentialed and privileged through the organized Medical staff structure

Initial Appointment / Clinical privileges/ practioners covered according to the NCQA
HP’s and MBHO’s must have documented Credentialing policies and procedures that apply to all practitioners who provide care to the organizations members

Initial Appointment / Clinical privileges/ practioners covered according to CMS
The Governing body determines, in accordance with Staye Law, which categories of practitioners are eligible for appointment to the medical staff. At a minimum the medical staff must be composed of MD ‘s and DO’s.

Verification of Medical education according to the TJC
Requires verification from the medical school or accepted PSV

TJC Accepted PSV for medical education
The AMA, the AOA, and the ECFMG

Verification of Medical education according to the NCQA
Requires HP/CVO the highest of three levels of education and training.

The three levels of education and training as defined by NCQA
Graduation from medical or professional school, residency, board certification.

Verification of Medical education according to CMS
The medical staff must have a mechanism to examine evidence of professional education

Verification of postgraduate training according to TJC
Requires verification from the primary source or designated equivalent sources.

TJC accepted PSV for postgraduate training
AMA and AOA

Verification of postgraduate training according to NCQA
The highest of the three levels of education and training attained. If board certified, than board certification suffices.

Verification of postgraduate training according to CMS
The medical staff must have a mechanism to examine evidence of training and documented experiences.

Verification of board certification according to TJC
The TJC standards do not specifically require verification of board certification, if the medical staff bylaws, policies, or rules and regulations require certification. However, it is an expectation that board certification be verified in some manner.

Verification of board certification according to NCQA
NCQA does not require board certification. If the individual is board certified verification may be obtained directly form the specialty board, AMA, or AOA.

ABMS certified Doctor Verification
Not recognized by the NCQA as a source for verification of board certification. The site is a consumer reference only

Verification of board certification according to CMS
CMS standards do not specifically mention board certification. The medical staff can not make its recommendation based solely on board certification, but must consider all elements of training and professional education.

Verification of current licensure according to TJC
Primary source verification is required from the State licensing board where the practitioner is requesting privileges.

What four times does TJC require verification of licensure
Initial appointment, re-appointment, licensure expiration and when new privileges are requested.

Verification of current licensure according to NCQA
The organization verifies that the practioners license is in those states where the practitioner provides care for the organizations members and that the practitioner possesses a valid current license or certification that is in effect and present in the file when the Credentialing committee makes its determination.

Verification of current licensure according to CMS
The medical staff must have a mechanism to examine evidence of current licensure.

NCQA current licensure verification time limit HP/MBHO
180 days

NCQA current licensure verification time limit CVO
120 days

Sanctions against licensure according to the TJC
Before recommending privileges, the following is evaluated: information regarding challenges to any censure or registration, voluntary or involuntary relinquishment of any licensure of registration.

Sanctions against licensure according to the NCQA
Information on sanctions, restrictions on licensure and limitations on scope of practice for the past five year must be obtained. If the individual was licensed in multiple states during the most recent five years, all states must be queried.

Sanctions against licensure according to CMS
CMS is silent regarding evaluation of licensure sanctions, however the interpretive guidelines do reference privileging criteria that consider the individuals character.

Verification of professional liability/ malpractice coverage according to TJC
PSV is not required if the medical staff bylaws, policies, or rules and regulations require professional liability coverage.

Source of verification of professional liability/malpractice according to TJC
Verification may come directly from the carrier or on the form of a copy of the applicants current professional liability policy binder that shows dates of coverage.

Verification of professional liability/ malpractice coverage according to NCQA
Verification may come directly from the carrier or on the form of a copy of the applicants current professional liability policy binder that shows dates of coverage.

NCQA time limits on professional liability /malpractice for HP/MBHO
The credentials information must be valid, current, and no more than 365 calendar days old at the time of the credentialing

NCQA time limits on professional liability /malpractice for CVO
The credentials information must be valid, current, and verified within 305 calendar days prior to submission to each client.

Verification of professional liability/ malpractice coverage according to CMS
PSV is not required, the requirement for professional liability coverage is common in healthcare , thus verification of coverage is appropriate.

Verification of malpractice history according to TJC.
The standards are silent regarding the specific method to accomplish this requirement , but it is suggested that the organized medical staff evaluate any evidence of unusual pattern or excessive numbers of professional liability actions resulting in a final judgment.

Verification of malpractice history according to NCQA
The applicant must provide at least a five-year history of malpractice settlements or judgments. This information is to be verified either through written comfirmation from the Malpractice carrier or through the NPDB.

NCQA malpractice verification time limits for HP/ MBHO
180 days

NCQA malpractice verification time limits for CVO
120 days

Verification of malpractice history according to CMS
CMS is silent regarding evaluation of malpractice history, however CMS does require organizations to be compliant with state and federal law.

Verification of work history according to TJC
TJC does not use the term “work history”. But does require evidence of current competence. Require that applicants provide a chronological history of education, training and experience.

Verification of work history according to NCQA
The applicant must provide a minimum of a five -year relevant work history statement on either the application or CV, which allows identification of gaps.

Verification of work history according to CMS
CMS does not use the term “work history”. But does require evidence of current competence. Require that applicants provide a chronological history of education, training and experience.